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E. Supervising NPPS
Physicians who employ NPPs should be very careful in their supervision. Because the
physician is liable for negligent medical care rendered by NPPs, a physician should
never accept responsibility for an NPP without having the authority to supervise or
decline to practice with the person. The physician is also liable for nonmedical actions
by the NPP, such as sexual assault, if the physician is negligent in screening or
supervising the NPP.
The first step in selecting or accepting supervision of an NPP is to check the person’s
credentials personally and carefully. The NPP’s license status must be checked in
every state where the NPP has held a license, not just the state where he or she will
work. The physician should find out the specifics of the NPP’s training and previous
experience to gauge skill levels. Finally, the physician should talk to other physicians
who have worked with the NPP, asking specifically about his or her willingness to
accept physician authority, clinical skills, and readiness to ask for consultation from
the physician. An NPP who worked well with a physician who checks every patient
and chart entry may not be compatible with a physician who prefers to delegate by
written protocols.
The physician should observe a newly hired NPP in providing patient care and by
repeating the physical assessment. It is not possible to know if the NPP recognizes a
bulging eardrum until the physician has reevaluated both negative and positive
findings by the NPP. This also gives the NPP the opportunity to learn the physician’s
preferences and practice habits, making both more comfortable with the arrangement.
Many conflicts over supervision arise because the physician never clearly
communicates his or her expectations to the NPP.
1. Scope of Practice
Every NPP should have a written scope of practice that specifically states what the
NPP may do on his or her own initiative, what requires protocol authorization, and
what must be referred to the physician. It should include specific instructions for
handling emergencies and urgent situations when the physician is unavailable. It
should specify types of patients that the NPP should or should not accept for care. If
the NPP is a licensed nurse, the scope of practice should delineate which activities
are nursing and which are delegated medical care. Like protocols, this scope of
practice should be agreed upon and signed by both the physician and the NPP. The
scope of practice should explicitly deal with both nursing diagnoses and what
constitutes unauthorized practice of medicine.
2. Documentation
Careful documentation is particularly important when NPPs are practicing medicine
under supervision, but it is not necessary or desirable to document every positive and
negative physical finding. Such charts will be hard to read and are unlikely to be
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